Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Type 2 diabetes raises serum sclerostin levels and disturbs the relation between sclerostin and bone mineral density: a call for caution with antisclerostin therapy in osteoporosis

Background Sclerostin is an osteocyte-secreted protein that negatively regulates osteoblasts. Wnt signaling may be crucial in the pathogenesis of impaired bone quality in type 2 diabetes mellitus (T2DM). The possibility that currently studied antisclerostin bone-forming agents could be useful to T2DM patients with osteoporosis needs further investigations. Aim The aim of this study was to investigate the relationship between serum sclerostin and bone mineral density in T2DM patients, in comparison with nondiabetic individuals. Patients and methods This study was conducted on 21 T2DM patients and 22 nondiabetic individuals. All participants were 60 years or older. They underwent history taking, clinical examination, routine lab investigations, and glycated hemoglobin assessment. Serum sclerostin was measured by ELISA. Bone mineral density (BMD) was measured at the left femoral neck and lumbar spine. Results Serum sclerostin level was significantly higher in T2DM patients compared with nondiabetic individuals. Male participants showed significantly higher sclerostin levels among the nondiabetic individuals, whereas this difference was not significant among T2DM patients. The Bone mineral density (BMD) and t-values of T2DM patients and the nondiabetic group were not significantly different. We found a significant positive correlation between sclerostin level and lumbar spine BMD among nondiabetic individuals, whereas among T2DM patients, this correlation was not significant. Sclerostin levels did not show a significant difference between diabetic osteoporotic and diabetic nonosteoporotic patients. Conclusion Patients with T2DM have raised sclerostin levels that, unlike those in nondiabetic individuals, are not correlated with BMD. This pathological condition that is specific to diabetes necessitates further study, careful assessment of the role of antisclerostin therapy, and probable dose adjustment for osteoporosis in T2DM patients

Analgesic effects of ultrasound guided paravertebral block versus transversus abdominis plane block in hepatic patients undergoing laparoscopic cholecystectomy: PVB vs TAP in hepatic patients

Background: Several analgesic modalities after laparoscopic cholecystectomy were used in hepatic patients but with various complications. Bilateral ultrasound-guided transverse abdominis plane block (TAP) or thoracic paravertebral block (PVB) may provide safer techniques than others. The aim of this study is to delineate the more efficient and safer technique either TAP or PVB in hepatic patients. Methods: The research was conducted on sixty adult hepatic patients, ASA II or III, Child A or B, undergoing laparoscopic cholecystectomy. Patients were allocated randomly into one of two equal groups, to attain bilateral ultrasound guided either PVB (Group P) or TAP block (Group T). Group P showed significant postoperative lower pain scores using visual analogue score at 2, 4, 6 and 24 h (P < 0.01) and less intraoperative desflurane and fentanyl consumption (P < 0.001) versus group T. In addition, group P exhibited less total postoperative pethidine requirement (23.3±25.4 mg vs. 38.3±21.5 mg, P = 0.017), fewer number of patients asked for postoperative analgesia (46.7% vs. 76.7%, P value = 0.017), longer duration to first analgesic demand (20.5±5.1 h vs. 15.1±8.4 h, P = 0.021), and compared to group T respectively. Regarding liver functions and haemodynamics, both groups were comparable at different intervals